NCC216674_FRO Submitted_20211201

Mecklenburg o ty Soil Erosion and
0k Sedimentation ControlOrdinance
Financial responsibility/Ownership For
No person shall initiate any land -disturbing activity covered by Section b of the Mecklenburg
County, Mint Hill or Davidson Sedimentation and Erosion Control Ordinances prior to
completing and ding this form with Mecklenburg County Land Use and Environmental
Services. The financially responsible party will be on record as the party to accept any Notices
of Violation or related documentsfor any non-compliance with the "above Ordinances. if the
financially responsible party is out of State, a North Carolina agent must be assigned.
Please Type or Print
ART
1. Project where land -disturbing activity is to be undertaken: Asbury Village
7110 Asbury Village Lane 17114 Asbury Village Lane
2. Address of land -disturbing activity:
7121 Asbury Village Lane / 7109 Asbury Village Lane
3. Approximate date land -disturbing activity will commence: Nov 12 2021
Month Day Year
4. purpose of development (Residential, Commercial, Industrial, etc.): Residential
5. An acreage of land to be disturbed or uncovered: 7110- 39ac17114-.43ac17121-.34/7109-.25ac
7110-1.05ac/7114`-1.04ac/7121-1.17aci
6. Total site acreage: 7109-1.42ac
7. Landowners of record (use blank pages to list additional owners as necessary):
Owner #1 Name: PH Developments LLB
Address: 14765 Caldefor i• Lane untersville NC 28078
Telephone: [phone] Fax:
Email Address: [e-mail]
Owner #2 Name:
Address:
'telephone Fax:
Email Address:
8. indicate Book and Page where the deed or instrument is filed (use blank pages to list
additional deeds or instruments as necessary):
Book 36504 Page 170 Book Page
Boole rage Book Page
(continue on back or separate pages as necessary)
Foal lRevised 12-2016

Continue - FinancialResponsibility/Ownership For
PART"
1. Person(s) or firm(s) financially responsible for this 'land -disturbing activity:
Person or Finn: PH Developments LLB
Address. 14765 Caldefard Lane Huntersyille NC 28078
Telephone: [phone] pax:
Email Address: [e-mail]
I North Carolina agent for the person or firm who is financially responsible:
Person or Flan: PH Developments LLB
Address. 14765 Caldeford Lane Huntersville NC 26076
`telephone: [phone] Fax:
Email Address: [e-mail]
3. the above information is true and correct to the best of my knowledge and belief and was
prodded by me while under oath. (This form must be signed by the financially responsible
person if an individual or by an officer, director, partner, attorney -in -fact, or other person
with authority to execute instruments for the financially responsible company or entity, if not
an individual.)
Gregory Perr It Owner
Title
11`/2/2021
a
Date
?% a Notary Public of the
County of OMWIM, State of No UMUNa , hereby
certify that �} 1�(�I K personally appeared
before tie this day and under oath acknowledged that this form was executed by him/her.
Witness my hand and notarial seal, this " �� day of 20
Notary Signature:
JONATHON PRATHER
y Commission expires:
Mecklenburg County
North Carolina
Mecklenburg County Land Use and Environmental Services Ag Conyni.,sion Expires Sep. 03, 202
2145 Suttle Ave.
Charlotte, NC 28208-5237
Phone [phone]